Provider Demographics
NPI:1649542390
Name:GODFREY, MYRTLE (COUNSELOR)
Entity type:Individual
Prefix:
First Name:MYRTLE
Middle Name:
Last Name:GODFREY
Suffix:
Gender:F
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 BOULDER DR
Mailing Address - Street 2:315
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613-5246
Mailing Address - Country:US
Mailing Address - Phone:319-961-1506
Mailing Address - Fax:
Practice Address - Street 1:3112 BOULDER DR
Practice Address - Street 2:315
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-5246
Practice Address - Country:US
Practice Address - Phone:319-961-1506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA103T00000X101YP2500X
IA1912048281103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional